Frozen shoulder

The shoulder joint sits inside a capsule of strong, flexible tissue that lets the arm move through a wide range. In a frozen shoulder that capsule becomes inflamed, then tightens and shrinks, and it is that loss of stretch that both hurts and stops the joint moving. The shoulder feels blocked, not just sore.

Often there is no clear trigger. In some people it follows an injury or an operation that stopped the arm moving normally, or a stroke that left the arm weak; it can also follow a heart attack, or another painful shoulder problem such as rotator cuff problems. It is more common in women and in people with a thyroid problem. Diabetes raises the chance as well, though no one is sure why, and that is one more reason to keep up your regular diabetes check-ups. It mostly affects people between about 40 and 60.

A frozen shoulder typically changes over time:

• A painful phase, in which aching in the shoulder builds, is often worse at night and disturbs sleep; sudden muscle pains, called spasms, may come too, especially at night
• A stiff phase, in which the pain may ease but movement becomes more and more limited, so reaching up, out to the side or behind your back becomes hard
• A thawing phase, as the shoulder gradually loosens again

The stiffness affects movement in every direction, and the shoulder will not move fully even when someone else moves your arm for you, which helps set it apart from other shoulder problems.

The story and an examination of the shoulder's movement, both when you move it and when someone moves it for you, usually make the diagnosis. The examination also looks for other sources of the pain and stiffness, such as a torn rotator cuff, shoulder arthritis or pain passed down from the neck.

An ultrasound scan in the consulting room, described on the ultrasound clinic page, can usually show the tendons and the joint while you are there. Where an X-ray or an MRI will add to the picture, Dr Borukhson arranges it.

Treatment aims to ease the pain and help movement come back while the shoulder recovers. It usually builds in steps:

• Pain relief. Moving the shoulder only gently, regular paracetamol, and if that is not enough, stronger painkillers for a short time or a steroid injection into the shoulder, which can settle the pain enough to let you use and exercise it. An ultrasound-guided injection puts the steroid precisely where it is needed.
• Getting movement back. Gentle shoulder exercises at home, and physiotherapy, usually for at least six weeks, with stretching and strengthening as the pain allows.
• Hydrodilatation. If the shoulder stays painful and stiff, an injection that combines a steroid and a local anaesthetic with a larger volume of salt water stretches the tight capsule. It is guided by ultrasound and can be uncomfortable at the time; most people find it very helpful, though for some the benefit is short-lived.
• Surgery. For the few whose shoulder does not free up despite these steps, keyhole surgery to release the tight capsule, or a manipulation of the joint under anaesthetic, followed by a programme of exercises.

You and Dr Borukhson settle the plan together.

Keeping the shoulder moving within comfort matters more than resting it, since holding it still makes the pain worse:

• Do the exercises you have been given regularly, and do not make up strenuous exercises of your own; gym equipment, for one, can make the pain worse
• Warm the shoulder with a heat pack or a covered hot water bottle, for no more than 20 minutes at a time
• Take paracetamol regularly if you need it, so that you can sleep and keep moving
• Lie on the good side at night, with the painful arm resting on a pillow, and carry on with daily tasks as comfort allows, rather than holding the arm still

The long course is the hardest part. Most shoulders recover good, comfortable movement in the end, and keeping appointments to review progress lets the plan change if recovery stalls.

A frozen shoulder is not dangerous, but some pictures are not a frozen shoulder at all, and the two lists below, with the paragraph that follows them, route them. Among them are a shoulder injured or put out of place, an arm that loses its strength or feeling without warning, arm pain coming from the heart, infection, a feverish illness that might be sepsis, severe pain in both shoulders, and pins and needles running down the arm with a sore neck.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• After an injury, a crack heard as it happened, or skin around it that has turned blue, grey or cold, since these can be signs of a broken bone
• Sudden weakness or numbness on one side, a drooping face or difficulty speaking, a sudden severe headache, sudden confusion or a seizure, or sudden loss of vision, any of which can be a stroke, even if it stops after a short time, and an arm that has suddenly gone weak or numb, with no fall, lift or injury behind it, is one of these signs
• An eye that suddenly and completely loses its sight
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Arm pain that comes on suddenly with pressure, heaviness or squeezing across the chest, which can mean a heart attack

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• Arm pain that is brought on by exercise, stress, emotion or the cold, rather than by a particular movement of the arm, and stops within a few minutes of rest, which can mean angina, a sign of a heart problem; NHS 111 will tell you where to be seen
• Pins and needles, or numbness or weakness that has come on gradually, spreading down the arm or into the hand, with neck pain, since a nerve pressed at the neck can cause it, and the spinal cord itself has to be ruled out the same day
• Pins and needles in the arm or hand that do not go away, or an arm or shoulder that has slowly lost its feeling or its strength, with no injury and no neck pain, since a nerve that is being pressed, at the neck or along the arm, has to be found the same day
• Severe pain in both shoulders, which can be polymyalgia rheumatica rather than a frozen shoulder; pain and stiffness in both shoulders that is not severe is for a GP once it has lasted more than a week, while a new headache, a tender scalp or jaw pain when chewing alongside it is a same-day matter, and any change in sight with it is for an eye casualty or urgent eye clinic that same day, since these can mean giant cell arteritis, though a headache that strikes suddenly and severely, or sight lost suddenly, however briefly, belongs to the first list
• Sudden or very bad shoulder pain, or a shoulder that has become weak since a fall or a heavy lift, short of the signs in the first list, since a torn tendon or a break has to be found; a shoulder that is painful, bruised or swollen after it slipped out of place is a 999 or A&E emergency
• A shoulder or arm that has changed shape, become badly swollen or grown a lump, or that feels hot or cold to the touch, with no injury behind it, since something serious has to be ruled out the same day

See a GP if shoulder pain and stiffness are not going away, or the pain makes it hard to move the arm, and contact your GP or physiotherapist if six to twelve weeks of exercises have brought no progress or the pain is getting worse. The slow stiffening and the ache of the painful phase, however bad at night, belong with the GP; the lists above are for a change, such as a shoulder that suddenly cannot be moved or a pain that is new or suddenly different. Night pain with weight you have lost without trying, night sweats, or feeling run down over weeks needs a GP within days, so that a cause other than a frozen shoulder is looked for; feeling unwell with a fever or shivers belongs to the same-day list. Tingling in the arm or hand that comes and goes, with no injury and no neck pain, can wait for a routine appointment with your GP, but an arm that turns numb or weak all at once, when no fall, lift or injury explains it, or numb after an injury, belongs to the first list. No referral is needed to be seen here; next-working-day appointments can almost always be arranged, and same-day appointments are sometimes possible. A shoulder or arm that looks deformed after a fall or knock, or a shoulder that is painful, bruised or swollen after it slipped out of place, is a 999 or A&E emergency; for a fall onto the shoulder with none of those and nothing from the first list, NHS 111 can tell you where to be seen. If you cannot tell how urgent something is, asking is never a mistake.

A shoulder that has become painful and stiff deserves an assessment, to confirm that it is a frozen shoulder and not another problem, and to put in place the pain relief, injection and exercises that can make the long recovery easier. If your shoulder has reached that point, the visit is worth booking.

What does the assessment for a frozen shoulder involve?

It can usually be recognised from the pattern and an examination: pain, often worst at night, then stiffness, and a shoulder that will not move fully even when someone else lifts the arm for you. The same examination checks for problems that can look similar, such as a rotator cuff tear or arthritis of the joint. An ultrasound scan in the clinic room can usually add a view of the tendons and the joint, and Dr Borukhson arranges an X-ray or an MRI where that will help.

How long does a frozen shoulder last?

It moves through phases: a painful phase, a stiff phase and then a slow recovery. The whole course often takes a year or more, and it can be two or three years before the shoulder is fully free. Most people get back good, comfortable movement in the end, and treatment is there to ease the pain and help movement return along the way.

What treatment helps?

Pain relief comes first, from regular paracetamol to a steroid injection into the shoulder, which can ease the pain enough to let you move it. Gentle exercises, and physiotherapy, can then help movement return. If the shoulder stays very painful or stiff, an injection that stretches the capsule with a larger volume of fluid, called hydrodilatation, often helps, and keyhole surgery to release the tight capsule is an option for the few who need it.

Why use ultrasound for the injection?

Ultrasound shows the inside of the shoulder on a screen while the injection is given, so the steroid, or the fluid in a hydrodilatation, goes exactly where it is meant to. Dr Borukhson gives shoulder injections under ultrasound guidance, and the decision about whether one is right is made with you as part of the plan.